HomeMy WebLinkAboutBLDP-25-534 MASS CHUSETTS UNIFORM Ai.APPLICATION
FOR A PERMIT TO PERFORM PLUMBING WORK
'vie,� CITY �(rMDU MA DATE tr.—PER IT#(SLD(-z.s5-14
JOB SITE ADDRESS OWNER'S NAME 5 yt gro,„<„,
OWNER ADDRESS 50X-TEL z8 Z- 7�/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL LPG
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO 21,
FIXTURES 1. FLOOR-, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE J _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _ _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _ _
LAVATORY •
ROOF DRAIN _
SHOWER STALL -
R-E C
SERVICE/MOP SINK T 'ter;`D
_ -
TOILET tom[
URINAL _ JUL 16 =025
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES n nFP RTMr NT
LDI 1G
WATER PIPING eYDU
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Irk NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbingi Code andChhaapter 142Qof the General Laws., 0.7
PLUMBERS NAME P4 ILO V�'-�J( r J-0 LIICCENSE 0 SIGNATURE
MP❑ JP❑ CORPORATIONRP 0# r'a)t PARTNERSHIP❑# LLC/❑�#�
COMPAN NAME L•1(�C� P I l� ^ ADDRESS 3 7 f�/�'t/)�(/✓� /�1"C/e-1�
CITY 1 GI n 4 t 5 STATE AAA ZIP t� l�J 0/ TEL 77V l/D 9/??
FAX GGGG CELL EMAIL 5/1,i jj ex•/T c t Sa g,5✓4i j•(Q,n1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES
4